Atlantische Themen 1/2018: Ein Jahr Trump-Administration

Snapshot on health care reform: the first year of Trump’s Administration

Betsy Leimbigler, Freie Universität Berlin

Last year, on the day after Donald Trump’s inauguration, millions around the world went out in vast numbers to protest during the global “Women’s March.” Protestors went out with innumerable reasons, voicing multiple issues and concerns for the new President. One of the many reasons for this display of resistance included concerns over health care. Women and men alike were concerned with the health care related rollbacks that Donald Trump’s administration had promised to initiate. Whether through the active disintegration of Medicaid, cutting access to reproductive rights, or simply passively allowing Obama-era health reforms to collapse on their own without funding, the resistance towards Donald Trump’s inauguration was intertwined with concepts of racial and socioeconomic justice, with a direct link to health and human rights. This resistance and criticism persisted throughout 2017.

The United States continues to be the only developed nation in the world without a comprehensive health care system that covers all citizens. The Affordable Care Act (ACA), colloquially referred to as “Obamacare,” passed in 2010 under President Obama with strong Republican opposition and didn’t guarantee universal coverage; however, it did decrease the percentage of uninsured from approximately 20.5% in 2013 to 12.2% in 2016. This past year, the Trump administration distanced U.S. health policy from the concept of health care as a human or social right, and parts of the Affordable Care Act were chipped away. Debates about the access to and the cost of birth control were revived and the individual mandate was removed.

This paper will highlight the year 2017 in terms of what it meant for the many repeal attempts of Obamacare, with a look at health care concerns of lower-income Americans and women in the era of a Republican controlled congress. The trends from 2017 indicate that the Trump Administration will continue to further the concept of health care as an individual privilege rather than a collective right, which has serious ramifications for the middle class, the poor, and women and minorities in particular.

Attempts at repealing Obamacare

Donald Trump made it a campaign promise to repeal Obamacare; something that Republicans have attempted to symbolically repeal dozens of times over the last decade. The Affordable Care Act contains many provisions aimed at ensuring more Americans can purchase health insurance. Among many other provisions, it expanded Medicaid coverage, removed discriminatory practices by insurance companies to deny patients with pre-existing conditions, ensured free birth control in insurance plans, gave financial incentives for doctors to see patients covered under Medicaid, and mandated the individual purchase of health insurance. It is certainly true that in recent years some states saw insurers leaving the marketplace and premiums rising too high for some people to afford; but rather than addressing and fixing the issues that Obamacare created, the entire Trump campaign and administration opted instead to focus on repealing it. Partisanship plays a large role in this rhetoric and course of action. This deadlock constitutes one reason for the repeated failures at “repealing Obamacare,” a complex law that has benefitted a great number of Americans that cannot be simply retracted.

There was a large amount of media fixation on the highly publicized attempts and subsequent failures to repeal and replace Obamacare in 2017. Some examples of these legislative failures include the cancellation of a repeal vote on March 24, 2017, when it became clear that the repeal wouldn’t have enough votes in the House. Republicans drafted up several alternate plans, one of which, the “American Health Care Act,” was estimated by the non-partisan Congressional Budget Office (CBO) to leave approximately 23 million Americans uninsured by 2026, effectively undoing a large portion of what was achieved through the Affordable Care Act. Variations of the bill with other names were also introduced. On July 28, 2017, three Republican senators voted against the so-called “skinny repeal” of Obamacare, constituting another roadblock for Republicans. After several failed attempts at repealing Obamacare, the administration finally managed to chip away at parts of the law by ending the individual mandate in their tax bill, passed in December 2017.

In practice, the Republican administration has not made affordable health care a priority for Americans. Instead, they focused their efforts on either attempting to repeal the Affordable Care Act by any means necessary, or on their only major achievement of the year: the tax reform bill.

Tax Reform bill – Trump’s achievement of the year

The tax bill is extremely relevant to the health care debate, considering that this bill removes the individual mandate of Obamacare. This effectively chips away at a part of Obamacare, but also underscores the point that Obamacare cannot be simply repealed; however, small parts of the Affordable Care Act can be phased out. Another incremental change with significant impact is the end to Cost-Sharing Reductions (CSRs), a mechanism to offset costs for insurers providing insurance to low-income Americans.

Women’s health and low income Americans

Obama-era health reforms focused on affordability of care and prescription drugs for various groups of people: Lower-income Americans through Medicaid expansion, middle-class Americans who did not receive health care through their employer, as well as access to birth control through plans that covered contraception. Given that women’s health has wider implications for infant mortality, maternal mortality, is closely related to poverty rates, and is also highly racialized, it is inextricably linked to health policy on contraception and abortion. The ACA expanded access to contraceptives for women; with over 20% of women paying for out of pocket contraceptives in 2012 compared to only 3.6% in 2014. Reproductive rights have been in the focus of the Trump administration for ideological reasons. In October 2017, the Trump Administration issued rules that loosen the requirements for employers and insurers to provide insurance coverage for contraceptives, based on religious or moral beliefs (Goldstein et al, 2017). This prompted Planned Parenthood to issue the following statement: “This administration is carrying out a full-scale attack on birth control--- eliminating insurance coverage for birth control, eliminating programs that help women with low incomes access birth control, and moving to prohibit health care providers from even giving women information about birth control or abortion” (Richards, 2017). As such, this constitutes one area in which an ACA element is being dismantled.

Health care has wide-reaching effects in society and is closely intertwined with poverty; Medicaid and Children’s Health Insurance Program (CHIP) cover over 74 million Americans. While the Affordable Care Act expanded those qualifying for Obamacare to those earning up to 400% of the poverty line, this was only implemented in the 32 states that accepted Medicaid expansion. The recently-passed tax bill will ensure an increase to the federal deficit, which does not bode well for continued funding at current rates for government-run health care programs.

Conclusion: health care as a privilege vs. a right

To sum up, the past year has shown two trends. The first is the incremental removal of certain specific mechanisms of Obamacare, without managing to fully remove or repeal the law. The second is the distancing of the administration from what Almgren calls the “social right to health care”. With the removal of Cost-Sharing Reductions and the individual mandate, and fears of upcoming cuts to Medicaid, the actions that have been taken with regard to health care reform this year have not reflected a rights-based approach to health care. The first year of the Trump administration has seen the passage of a bill and the usage of rhetoric that reinforces the concept of health care in the U.S. as an individual privilege rather than a collective right. In terms of health care reform, this is a most distinct point of departure from the previous administration. The tax bill’s cuts have wider implications for wealth disparities in the years to come, specifically with regard to impact on health care and welfare. This is one of the reasons for which the U.N special rapporteur on extreme poverty and human rights called the most recent budget bill America’s “bid to become the most unequal society in the world” (United Nations Human Rights Office of the High Commissioner, 2017). An important takeaway from 2017 highlights how the repeal of the entirety of Obamacare is effectively impossible, as proven multiple times by the Republican failures. However, slow but sure attempts at partisan, incremental repealing of provisions that were made through the ACA have begun, and the attempts likely will continue – but the resistance against these changes will also continue.

About the author

Betsy Leimbigler is PhD Candidate at the John F. Kennedy Institute, Freie Universität Berlin, Germany. Her research focuses on success and failure of health care reform in the United States.